Body Dysmorphic Disorder and the Cult of Celebrity>8/1/2006 3:30:33 PM

In a medical setting, be it primary care provider’s office, hospital ER or therapist session, diagnosing body dysmorphic disorder (BDD) can often be tricky. While the disease may be just as or more prevalent than other mental health disorders, it rarely has the same name cache and is even more rarely discussed in mainstream media outlets. There really is no secret about why that might be. One need only open an issue of any one of the many celebrity gossip rags: Star Magazine, UsWeekly or InTouch, to see that we implicitly condone fetishistic body mutilation in the name of “beauty.” These magazine parade celebrities across their covers flaunting their most recent surgeries, not just normalizing their behavior, but indeed celebrating it.

The DSM IV provides three necessary criteria for diagnosis of body dysmorphic disorder.

Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

A 2001 study found that approximately 0.7% of women experience BDD, although other studies have found incidence rates to be higher. Most place estimates at 1 to 2% of the population. The disorder has been found to have high rates of comorbidity with other mental health problems, major depression and anxiety disorders chief among them. Rates of BDD in psychiatric outpatients have been found to be around 12-13%. While hard numbers are difficult to come by, it is believed that men and women are affected at roughly similar rates, while the exact forms of their presentations may differ slightly.

Numbers have been notoriously hard to pin down due to the very nature of the disease. More often than not, sufferers keep their disorder very secretive. Many BDD sufferers live with their disease in secret for years and even decades. A major factor in the disease, and one that separates it from obsessive compulsive disorder to which it has been closely linked, is that those dealing with BDD typically have poor insight, believing beyond reason that their imagined defects are real and apparent. This creates a feeling of needing to camouflage. In less severe cases this might present as a man wearing a baseball cap. A more severe example might be a man who dresses in long pants and sleeves even in the middle of summer to hide what he considers excessive body hair.

What all of this information points to is a situation where BDD is under diagnosed, or even incorrectly diagnosed as one of a number of disorders. Major depressive disorder, social anxiety disorder, OCD and even schizophrenia can all present similar symptoms, but doctors trained to ask the right questions may soon realize that what they are really dealing with is BDD. The failure to diagnose BDD properly is all the more frightening when one considers the disorder’s strong link to suicidal ideation and attempted suicide. As many as 80% of BDD patients have been found to experience suicidal ideation, while as many as 25% have attempted suicide.

Many who suffer from BDD will avoid seeking help from a therapist or even a general practitioner, instead presenting at a plastic surgeon to try to correct their perceived abnormality with cosmetic surgery. Unfortunately, this behavior usually only leads to further surgeries or a shift in the nature of the preoccupation, even culminating in horrific outcomes when surgery is refused. Prozac and other SSRIs have been found to be effective in treatment. Cognitive behavioral therapy has also been shown to provide relief.

It is during this interview that Dr. Phillips directly addresses the question of our culture and the media and their effects on the rates of BDD. While she says that there have been descriptions in medical literature for over 100 years of patients dealing with symptoms that indicated BDD, Dr. Phillips doesn’t let changing societal expectations off the hook:

Appearance has always been important. But I suspect it's possible that the rate of B.D.D. is increasing, as women get bombarded with media images of perfection. Lots of studies have shown that the more you see images of perfection around you, and the more you compare yourself with those images, the worse you tend to feel about yourself.

If anything, Dr. Phillips lets our modern celebrity obsessed culture off the hook. Star Magazine provides a startling example of the damaging messages that are propagated time and again, especially in tabloid media outlets. We began receiving Star at our New York City office without ever ordering a subscription and with no forewarning. In this brief analysis, we will look only at the most recent issue.

The cover of the Aug. 7th issue shows former TV star Shannen Doherty with a headline that screams: Extreme Makeover! Buried inside the magazine is the “story,” in which three plastic surgeons weigh in on whether or not the 35-year-old actress has had cosmetic surgery to her face. Here the headline reads “Knifestyles of the Rich and Famous.” Clever.

In the paltry 200+ words, spread over two pages, the “writers” draw attention to Ms. Doherty’s lips and cheeks, which all the paid-consulting doctors agree have been surgically altered with surgery costing anywhere from $4,000 to $7,000. All of this is done while comparing a picture of Doherty from 1992 with one from this year. Their verdict: “Then – Less Cheeky & Lippy” whereas “Now – Major Trout Pout!” The tone is somewhat condescending and judgmental, which might make one think that Star was anti-surgery. This is completely undercut and inverted however, by the very existence of such an article, not to mention its placement on the cover.

Even more disturbing is the case of 21-year-old Ashlee Simpson, the younger sister of Jessica Simpson. There has been no small amount of discourse among the media and the blogsphere surrounding Ashlee’s makeover and subsequent signing as a spokeswoman for Victoria Secret. All of this came to a head recently with a flap over an interview in Marie Claire last month in which Ms. Simpson extols the virtues of being happy with yourself as you are, while at the same time getting a highly publicized rhinoplasty.

The Star Magazine coverage takes a much, much lower road. Their article is titled simply: “Jessica vs. Ashlee: Who’s Prettier Now?” If that left too much to the imagination for you, the next four pages lay out in full color the “feud” between the sisters. Star’s experts break down who outdoes whom in hair, makeup, body, lips and even boyfriend. Here is absent all the subtle criticism of the actual decision to go under the knife that we saw with Shannen Doherty. The implicit message is that if you can look good (and boy, do the “experts” think Ashlee looks good), then maybe having plastic surgery, at the age of 21 or even younger as Ashlee was rumored to have done, is not such a big deal. There’s no discussion of her nearly flawless appearance pre-surgery, instead the focus is placed on her “great new look.”

These are only two examples in a magazine filled with image after image of women who set outrageous and unrealistic standards—princesses with a full staff to primp and perm them for hours before they set foot outside. And don’t let us make it seem as if men are not held to similarly high standards. In a section titled “Hollywood’s 11 Biggest Playboys” there are numerous images of male celebrities, each meticulously coifed and impeccably manicured with only a single bald head (sorry, Bruce Willis).

The fact of the matter is that Star is just one magazine, and only represents a small part of a culture that places significant importance on appearance. Each generation we become more and more a culture obsessed with image, the visual, the screen. When we are forced to look at these examples of beauty, day in and day out, is it any surprise that a disease like body dysmorphic disorder could rear its head. One of the most noticeable signs of a potential BDD sufferer is obsessive mirror checking. Considering the virtual assault of images of well-tanned and perfectly fit celebrities, whom we are being commanded to see at nearly every turn, how surprising is an unhealthy obsession with making sure our own image is one we are happy to portray to the rest of the world?